Please choose the statement that comes closest to describing you in the last two weeks.

No pain and no disturbing body sensations. Mild pain or disturbing body sensations that do not limit any activities (for example: work, social, sexual, sleep). Moderate pain or disturbing body sensations that limit a few activities. Moderate to severe pain or disturbing body sensations that limit some activities. Severe pain or disturbing body sensations that limit many activities.

2. Energy

Please choose the statement that comes closest to describing you in the last two weeks.

Very full of energy, lots of pep. Fairly energetic, no limitation of activities (for example: work, social, sexual). Moderate reduction in energy or pep that limits a few activities. Generally low energy or pep that limits some activities. No energy or pep at all. I feel drained, and many activities are limited.

3. Support From Family and Friends

Please choose the statement that comes closest to describing you in the last two weeks.

Most of the time feel supported by my spouse, family and friends. A fair amount of the time feel supported by my spouse, family and friends. Occasionally feel supported by my spouse, family and friends. Rarely feel supported by my spouse, family, and friends.

4. Communication With Doctor (primary caregiver for prostate cancer, may be specialist or family doctor)

Please choose the statement that comes closest to describing you in the last two scheduled appointments.

Always able to express my concerns to my Doctor and get all the information or advice I need. Most the time, able to express my concerns to my Doctor and get all the information or advice I need. Some of the time, able to express my concerns to my Doctor and get all the information or advice I need. Rarely able to express my concerns to my Doctor and get all the information or advice I need.

5. Emotional Well-Being

Please choose the statement that comes closest to describing you in the last two weeks.

Generally happy and free from worry, sadness, or frustration. A little worry, sadness, or frustration. Moderate worry, sadness, or frustration. Quite a bit of worry, sadness, or frustration. Extreme worry, sadness, or frustration.

6. Urinary Frequency (need to pass urine frequently during the day or night) and Urgency (difficulty delaying urination after the urge is felt to urinate, ability to "hold it")

Please choose the statement that comes closest to describing you in the last two weeks.

No urinary frequency or urgency. A little urinary frequency or urgency, does not interfere with sleep or other activities (for example: work, social); no need to plan ahead. Some urinary frequency or urgency that interferes with sleep or other activities; may need to plan ahead. Quite a bit of urinary frequency or urgency; need to be near a bathroom most of the time. Extreme urinary frequency or urgency; need to be near a bathroom always.

7. Leaking Urine/Poor Bladder Control

Please choose the statement that comes closest to describing you in the last two weeks.

Never, under any circumstances leak urine or lose bladder control. On rare occasions, leak urine or lose bladder control, does not interfere with any activities (for example: work, social, sexual, sleep). Occasionally leak urine or lose bladder control, interferes with a few activities. A moderate amount of the time, leak urine or lose bladder control, interferes with some activities. Most of the time, leak urine or have poor bladder control, interferes with many activities. Require a clamp, catheter, or collecting bag because of leaking urine or poor bladder control.

8. Sexual Function (problems with achieving/maintaining an erection)

Please choose the statement that comes closest to describing you in the last two weeks.

Full erections sufficient for intercourse. Erections sufficient for intercourse, but some reduction in firmness. Erections sufficient for masturbation or foreplay only. Erections, but not firm enough for any sexual activity. No erections at all.

9. Sexual Interest/Drive

Please choose the statement that comes closest to describing you in the last two weeks.

Normal amount of sexual drive and interest for you. A little decrease of sexual drive or interest for you. Moderate decrease of sexual drive or interest for you. Substantial decrease of sexual drive or interest for you. No sexual drive or interest.

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